Basic Information
| Provider Information | |||||||||
| NPI: | 1386753390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTICS MANAGEMENT INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MULBERRY DIAGNOSTIC IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 TAYLOR RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361177790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361061113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342649729 | ||||||||
| FaxNumber: | 3342649729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | WELCH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3342649729 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 00007581 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 051004010 | 01 | AL | BCBS | OTHER | 102425 | 05 | AL | MEDICAID |